Letters to the Editor
Olecranon Bursitis as a Complication of Tardive Dyskinesia
Dear Editor:
Tardive dyskinesia (TD) is associated with numerous complications.
Medical complications include disturbances of gait and posture,
dysphagia, dysarthria, and loosening of natural and artificial teeth
(1). Respiratory irregularities, aspiration pneumonia (2), and rib
fractures (3) have also been described. Psychosocial complications
include suicide, occupational impairment, social stigmatization
(1), and impaired sexual intercourse (4). This report describes
an unusual case of olecranon bursitis (OB) as a complication of
TD.
A 56-year-old man, treated for refractory schizophrenia since age
19 years, with paranoid delusions, auditory hallucinations, thought
disorder, and episodes of aggression was managed for many years
on fluphenazine decanoate. Subsequently, his daily medication for
6 years consisted of haloperidol 60 mg, chlorpromazine 1250 to 1800
mg, lithium 900 mg, procyclidine 15 mg, and diazepam 20 mg. Because
he developed a bluish skin discolouration (5), chlorpromazine was
replaced by loxapine 300 mg daily. Other medications remained unchanged.
He remained on this combination for 4 years. In December 1997, in
addition to his psychosis, he manifested parkinsonism and akathisia.
Olanzapine was prescribed and loxapine reduced. In May 2000, he
showed prominent TD affecting the extremities and, to a lesser degree,
the bucco-oral region. When seated, his TD arm movements resulted
in his rubbing both elbows against the arms of the chair.
At the end of July, he presented to the emergency room with a swollen,
red, painful left elbow and lesser involvement of the right elbow.
There were abrasions over both elbows and his white cell count was
elevated. A tentative diagnosis of septic OB was made. The left
elbow was drained, and he was treated with oral cephalexin. The
fluid showed an increase in neutrophils but no bacterial growth.
His daily psychiatric medication at this time consisted of loxapine
50 mg, olanzapine 20 mg, procyclidine 15 mg, and quetiapine 50 mg
. He returned 3 days later with persistent symptoms and was admitted
for a 2-day course of IV cefazoline, as well as oral antibiotics.
The condition improved, but in September 2000 there was persistent
swelling, with draining of a yellow, odorless fluid from the left
olecranon bursa. Dyskinetic movement of his arms continued, resulting
in repeated trauma to the elbows when seated. Because of persistent
bursitis, he underwent a bursectomy at the end of October.
Postoperatively, there was incomplete healing with persistent drainage.
In December 2000, a culture of the discharge revealed a coagulase-negative
staphyloccocal infection. Over the ensuing months, he received repeated
courses of antibiotics for recurrent infection. The skin over the
elbows was noted to be scraped. By the end of September 2001, the
wound had healed. His medication at this point was clopixol depot
250 mg every 2 weeks and daily valproic acid 1500 mg, loxapine 90
mg, procyclidine 10 mg, propranolol 30 mg, and oxazepam 30 mg. The
improvement in the wound was associated with a marked decrease in
dyskinetic arm movements.
As far as we know, OB as a complication of TD has not been previously
described. In a series of 20 patients with septic OB, Ho and others
noted that 1 patient had schizophrenia together with diabetes mellitus
(6). There was, however, no recent trauma to the elbow. Laupland
and others reported that 2/118 patients with septic OB had a comorbid
psychiatric illness (type and details not given) (7). Neither report
mentioned the presence of TD. In our patient, direct observation
of his TD movements and the presence of abrasions over his elbows
point to a cause-effect relation between TD, OB, and recurrent infections.
His movement disorder also resulted in delayed postoperative healing
and recurrent infections that only resolved with lessened TD.
References
1. Yassa R, Jones BD. Complications of tardive dyskinesia:
A review. Psychosomatics 1985;26:305–13.
2. Yassa R, Lal S. Respiratory irregularity and tardive
dyskinesia. Acta Psychiatr Scand 1986;73:506–10.
3. Szymanski S, Lieberman JA, Safferman A, Galkowski
B. Rib fractures as an unusual complication of severe tardive dystonia.
J Clin Psychiatry 1993;54:160.
4. Yassa R, Lal S. Impaired sexual intercourse as a
complication of tardive dyskinesia. Am J Psychiatry 1985;142:1514–5.
5. Lal S, Bloom D, Silver B, Desjardins B, Krishnan
B, Thavundayil J, and others. Replacement of chlorpromazine with
other neuroleptics: effect on abnormal skin pigmentation and ocular
changes. J Psychiatr Neurosci 1993;18:173–7.
6. Ho G, Tice AD, Kaplan SR. Septic bursitis in the
prepatellar and olecranon bursae. Ann Intern Med 1978;89:21–7.
7. Laupland KB, Davies HD. Olecranon septic bursitis
managed in an ambulatory setting. Clin Invest Med 2001;24:171-8.
Samir Patel, MD
Samarthji Lal, MD, FRCPC
Montreal, Quebec
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